Rosuvastatin and cardiovascular events in patients undergoing hemodialysis

Effect of statin on life prognosis in Japanese patients undergoing hemodialysis

The effect of statin on hemodialysis patients is controversial. Although previous large-scale studies did not clarify its effect in this population, recent studies suggest that statins could be useful in reducing the risk of cardiovascular events and all-cause mortality in specific groups of patients undergoing hemodialysis. The aforementioned large-scale studies included a small percentage of Asians, and few studies have investigated the effects of statins in Asians undergoing hemodialysis. Thus, we investigated the benefits of statins in patients undergoing maintenance hemodialysis at a single center in Japan. We obtained demographic, clinical, and hemodialysis data of all patients who underwent maintenance hemodialysis at the Nagasaki Renal Center between July 2011 and June 2012. Patients were followed-up until June 2018. We studied 339 patients, of which 51 (15.0%) were prescribed pitavastatin. The mean observation period was 4.1±2.3 years, 43% were women, and the median hemodialysis vintage at baseline was 4.7 years. During the follow-up, 198 patients (58%) died, of which 22 (43%) were prescribed pitavastatin and 176 (61%) were not prescribed any statins. After propensity score matching based on age, sex, dialysis vintage, dialysis time, diabetes mellitus, ischemic heart disease, dry weight, left ventricular ejection fraction, and serum albumin, an intergroup comparison between those who received statins and those who did not (44 patients in each group) showed significant differences in survival rate based on the log-rank test (P<0.05). Although the causes of death did not differ significantly between groups, deaths due to cardiovascular events, infections, and cancer were fewer in the group prescribed statins. Our results suggest that statins may reduce mortality in Japanese patients undergoing maintenance hemodialysis. Although potential residual confounders exist, statins may have an influence on the reduction in the incidence of cardiovascular events, infections, and cancer. Nevertheless, further studies are required to prove this hypothesis.

Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines

Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.

Protocol for the Study of Heart and Renal Protection-Extended Review: Additional 5-Year Follow-up of the Australian, New Zealand, and Malaysian SHARP Cohort

Background:

There are limited studies on the effects of statins on outcomes in the moderate chronic kidney disease (CKD) population and their trajectory to end-stage kidney disease.

Objective:

To examine the long-term effects of lipid-lowering therapy on all-cause mortality, cardiovascular morbidity, CKD progression, and socioeconomic well-being in Australian, New Zealand, and Malaysian SHARP (Study of Heart and Renal Protection) trial participants—a randomized controlled trial of a combination of simvastatin and ezetimibe, compared with placebo, for the reduction of cardiovascular events in moderate to severe CKD.

Design:

Protocol for an extended prospective observational follow-up.

Setting:

Australian, New Zealand, and Malaysian participating centers in patients with advanced CKD.

Patients:

All SHARP trial participants alive at the final study visit.

Measurements:

Primary outcomes were measured by participant self-report and verified by hospital administrative data. In addition, secondary outcomes were measured using a validated study questionnaire of health-related quality of life, a 56-item economic survey.

Methods:

Participants were followed up with alternating face-to-face visits and telephone calls on a 6-monthly basis until 5 years following their final SHARP Study visit. In addition, there were 6-monthly follow-up telephone calls in between these visits. Data linkage to health registries in Australia, New Zealand, and Malaysia was also performed.

Results:

The SHARP-Extended Review (SHARP-ER) cohort comprised 1136 SHARP participants with a median of 4.6 years of follow-up. Compared with all SHARP participants who originally participated in the Australian, New Zealand, and Malaysian regions, the SHARP-ER participants were younger (57.2 [48.3-66.4] vs 60.5 [50.3-70.7] years) with a lower proportion of men (61.5% vs 62.8%). There were a lower proportion of participants with hypertension (83.7% vs 85.0%) and diabetes (20.0% vs 23.5%).

Limitations:

As a long-term follow-up study, the surviving cohort of SHARP-ER is a selected group of the original study participants, which may limit the generalizability of the findings.

Conclusion:

The SHARP-ER study will contribute important evidence on the long-term outcomes of cholesterol-lowering therapy in patients with advanced CKD with a total of 10 years of follow-up. Novel analyses of the socioeconomic impact of CKD over time will guide resource allocation.

Trial Registration:

The SHARP trial was registered at ClinicalTrials.gov NCT00125593 and ISRCTN 54137607.

Effects of Liraglutide Versus Placebo on Cardiovascular Events in Patients With Type 2 Diabetes Mellitus and Chronic Kidney Disease

BACKGROUND

LEADER trial (Liraglutide Effect and Action in Diabetes: Evaluation of CV Outcome Results) results demonstrated cardiovascular benefits for patients with type 2 diabetes mellitus at high cardiovascular risk on standard of care randomized to liraglutide versus placebo. The effect of glucagon-like peptide-1 receptor agonist liraglutide on cardiovascular events and all-cause mortality in patients with type 2 diabetes mellitus and chronic kidney disease is unknown. Liraglutide's treatment effects in patients with and without kidney disease were analyzed post hoc.

METHODS

Patients were randomized (1:1) to liraglutide or placebo, both in addition to standard of care. These analyses assessed outcomes stratified by baseline estimated glomerular filtration rate (eGFR; <60 versus ≥60 mL/min/1.73 m²) and baseline albuminuria. The primary outcome (composite of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) and secondary outcomes, including all-cause mortality and individual components of the primary composite outcome, were analyzed using Cox regression.

RESULTS

Overall, 2158 and 7182 patients had baseline eGFR <60 or ≥60 mL/min/1.73 m², respectively. In patients with eGFR <60 mL/min/1.73 m², risk reduction for the primary composite cardiovascular outcome with liraglutide was greater (hazard ratio [HR], 0.69; 95% CI, 0.57-0.85) versus those with eGFR ≥60 mL/min/1.73 m² (HR, 0.94; 95% CI, 0.83-1.07; interaction P=0.01). There was no consistent effect modification with liraglutide across finer eGFR subgroups (interaction P=0.13) and when analyzing eGFR as a continuous variable (interaction P=0.61). Risk reductions in those with eGFR <60 versus ≥60 mL/min/1.73 m² were as follows: for nonfatal myocardial infarction, HR, 0.74; 95% CI, 0.55-0.99 versus HR, 0.93; 95% CI, 0.77-1.13; for nonfatal stroke, HR, 0.51; 95% CI, 0.33-0.80 versus HR, 1.07; 95% CI, 0.84-1.37; for cardiovascular death, HR, 0.67; 95% CI, 0.50-0.90 versus HR, 0.84; 95% CI, 0.67-1.05; for all-cause mortality, HR, 0.74; 95% CI, 0.60-0.92 versus HR, 0.90; 95% CI, 0.75-1.07. Risk reduction for the primary composite cardiovascular outcome was not different for those with versus without baseline albuminuria (HR, 0.83; 95% CI, 0.71-0.97; and HR, 0.92; 95% CI, 0.79-1.07, respectively; interaction P=0.36).

CONCLUSIONS

Liraglutide added to standard of care reduced the risk for major cardiovascular events and all-cause mortality in patients with type 2 diabetes mellitus and chronic kidney disease. These results appear to apply across the chronic kidney disease spectrum enrolled.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov/ . Unique identifier: NCT01179048.

The Association of Atrial Fibrillation and Ischemic Stroke in Patients on Hemodialysis: A Competing Risk Analysis

Background

Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear.

Objective

The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses.

Design

A national record linkage cohort study.

Setting

All renal and stroke units in Scotland, UK.

Patients

All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015).

Measurements

Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records.

Methods

Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke.

Results

Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death.

Limitations

Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available.

Conclusions

The incidence of stroke in HD patients is high. The competing risk of "prestroke" mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes.

Health economic evaluation of peritoneal dialysis based on cost-effectiveness in Japan: a preliminary study

BACKGROUND

In Japan, the medical expenditures associated with dialysis have garnered considerable interest; however, a cost-effectiveness evaluation of peritoneal dialysis (PD) is yet to be evaluated. In particular, the health economics of the "PD first" concept, which can be advantageous for clinical practice and healthcare systems, must be evaluated.

METHODS

This multicenter study investigated the cost-effectiveness of PD. The major effectiveness indicator was quality-adjusted life year (QALY), with a preference-based utility value based on renal function, and the cost indicator was the amount billed for a medical service at each medical institution for qualifying illnesses. In comparison with hemodialysis (HD), a baseline analysis of PD therapy was conducted using a cost-utility analysis (CUA). Continuous ambulatory PD (CAPD) and automated PD (APD) were compared based on the incremental cost-utility ratio (ICUR) and propensity score (PS) with a limited number of cases.

RESULTS

The mean duration since the start of PD was 35.0±14.4 months. The overall CUA for PD (179 patients) was USD 55,019/QALY, which was more cost effective (USD/monthly utility) compared with that for HD for 12-24 months (4,367 vs. 4,852; p<0.05). The CUA reported significantly better results in the glomerulonephritis group than in the other diseases, and the baseline CUA was significantly age sensitive. The utility score was higher in the APD group (mean age, 70.1±3.5 years) than in the CAPD group (mean age, 70.6±4.2 years; 0.987 vs. 0.860; p<0.05, 9 patients). Compared with CAPD, APD had an overall ICUR of USD 126,034/QALY.

CONCLUSION

The cost-effectiveness of PD was potentially good in the elderly and in patients on dialysis for <24 months. Therefore, the prevalence of PD may influence the public health insurance system, particularly when applying the "PD first" concept.

Safety and efficacy of statin therapy

The 2013 ACC/AHA guidelines on blood cholesterol management were a major shift in the delineation of the main patient groups that could benefit from statin therapy and emphasized the use of higher-intensity statin therapies. In 2016, an expert consensus panel from the ACC recommended the use of nonstatin therapies (ezetimibe and PCSK9 inhibitors) in addition to maximally tolerated statin therapy in individuals whose LDL-cholesterol and non-HDL-cholesterol levels remained above certain thresholds after statin treatment. Given the substantial benefits of statin therapies in both primary and secondary prevention of cardiovascular disease, their long-term safety has become a concern. The potential harmful effects of statin therapy on muscle and liver have been known for some time, but new concerns have emerged regarding the risk of new-onset diabetes mellitus, cognitive impairment and haemorrhagic stroke associated with the use of statins and the risks of achieving very low levels of LDL cholesterol. The increased media attention on the adverse events associated with statins has unfortunately led to statin therapy discontinuation, nonadherence to therapy or concerns about initiating statin therapy. In this Review, we explore the safety of statin therapy in light of the latest evidence and provide clinicians with reassurance about the safety of statins. Overwhelming evidence suggests that the benefits of statin therapy far outweigh any real or perceived risks.

Peritonitis Affects the Relationship Between Low-Density Lipoprotein Cholesterol and Cardiovascular Events in Peritoneal Dialysis Patients

BACKGROUND

In peritoneal dialysis (PD), the relationship among low-density lipoprotein cholesterol (LDL-C), peritonitis, and cardiovascular (CV) disease has not been clarified. This study was performed to explore their associations in a large PD cohort.

METHODS

This retrospective cohort study included incident patients who received PD catheter insertion in our centre. The primary outcome was the first CV event (nonfatal myocardial infarction, CV death, non-haemorrhagic stroke, or any arterial revascularization procedure). Secondary outcomes were the occurrence of peritonitis, CV mortality, and all-cause mortality.

RESULTS

This study included 1294 patients, whose mean age was 48.1 years. After adjustment for confounders in negative binomial regression models, lower LDL-C quartiles were independently associated with a higher risk of peritonitis, compared with the highest quartile. The multivariate competing risk model showed no significant association between baseline LDL-C and the first CV event in the overall population. However, stratified analysis showed that each 1 mmol/L increase in LDL-C was independently associated with a 21% (subdistribution hazard ratio: 1.21, 95% confidence interval: 1.06-1.39) increased risk of the first CV event among peritonitis-free patients, and with a 20% (subdistribution hazard ratio: 0.80, 95% confidence interval: 0.65-0.99) decreased risk among patients with peritonitis. Moderating-effect analysis showed that the presence of peritonitis significantly influenced the relationships between LDL-C and CV events (P < 0.001). Similar results were also observed in the relationship between LDL-C and mortality.

CONCLUSIONS

PD patients with lower baseline LDL-C had a higher risk of peritonitis. The effect of LDL-C on CV events and mortality was different by the presence of peritonitis events.

Lipid management in patients with chronic kidney disease

An increased risk of cardiovascular disease, independent of conventional risk factors, is present even at minor levels of renal impairment and is highest in patients with end-stage renal disease (ESRD) requiring dialysis. Renal dysfunction changes the level, composition and quality of blood lipids in favour of a more atherogenic profile. Patients with advanced chronic kidney disease (CKD) or ESRD have a characteristic lipid pattern of hypertriglyceridaemia and low HDL cholesterol levels but normal LDL cholesterol levels. In the general population, a clear relationship exists between LDL cholesterol and major atherosclerotic events. However, in patients with ESRD, LDL cholesterol shows a negative association with these outcomes at below average LDL cholesterol levels and a flat or weakly positive association with mortality at higher LDL cholesterol levels. Overall, the available data suggest that lowering of LDL cholesterol is beneficial for prevention of major atherosclerotic events in patients with CKD and in kidney transplant recipients but is not beneficial in patients requiring dialysis. The 2013 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Lipid Management in CKD provides simple recommendations for the management of dyslipidaemia in patients with CKD and ESRD. However, emerging data and novel lipid-lowering therapies warrant some reappraisal of these recommendations.

Association Between Baseline, Achieved, and Reduction of CRP and Cardiovascular Outcomes After LDL Cholesterol Lowering with Statins or Ezetimibe: A Systematic Review and Meta-Analysis

Background Several lipid-lowering therapies reduce CRP (C-reactive protein) independently of LDL-C (low-density lipoprotein cholesterol) reduction, but the association between CRP parameters and benefits from more-intensive LDL-C lowering is inconclusive. We aimed to determine whether the benefits of more- versus less-intensive LDL-C lowering on cardiovascular events related to baseline, achieved, or magnitude of reduction in CRP concentrations. Methods and Results PubMed, EMBASE, and Cochrane were searched through July 2, 2018. We included randomized controlled cardiovascular outcome trials of LDL-C lowering with statins or ezetimibe. Two reviewers independently extracted study data and rated study quality. Data were analyzed using meta-analysis and metaregression analysis. Rate ratios of mortality and cardiovascular outcomes associated with baseline, achieved, and magnitude reduction of CRP concentration were calculated. Twenty-four trials were included, with 171 250 patients randomly assigned to more- or less-intensive LDL-C-lowering treatments. Median follow-up duration was 4.2 years. More-intensive LDL-C lowering resulted in a significant reduction in incidences of all outcomes. Compared with less-intensive LDL-C lowering, more-intensive LDL-C lowering was associated with less reductions in myocardial infarction with a higher baseline CRP concentration (change in rate ratios per 1-mg/L increase in log-transformed CRP, 1.12 [95% CI, 1.04-1.22; P=0.007]), but not other outcomes. Similar risk reductions occurred for more- versus less-intensive LDL-C-lowering therapy regardless of the magnitude of CRP reduction or the achieved CRP level for all outcomes. Conclusions Baseline CRP concentrations might be associated with the benefits of LDL-C lowering on myocardial infarction, but no other outcomes, whereas the achieved and magnitude of reduction in CRP did not seem to have an important association.

Cardiovascular Outcomes Reported in Hemodialysis Trials

Patients on long-term hemodialysis are at very high risk for cardiovascular disease but are usually excluded from clinical trials conducted in the general population or in at-risk populations. There are no universally agreed cardiovascular outcomes for trials conducted specifically in the hemodialysis population. In this review, we highlight that trials reporting cardiovascular outcomes in hemodialysis patients are usually of short duration (median 3 to 6 months) and are small (59% of trials have <100 participants). Overall, the cardiovascular outcomes are very heterogeneous and may not reflect outcomes that are meaningful to patients and clinicians in supporting decision making, as they are often surrogates of uncertain clinical importance. Composite outcomes used in different trials rarely share the same components. In a field in which a single trial is often insufficiently powered to fully assess the clinical and economic impact of interventions, differences in outcome reporting across trials make the task of meta-analysis and interpretation of all the available evidence challenging. Core outcome sets are now being established across many specialties in health care to prevent these problems. Through the global Standardized Outcomes in Nephrology-Hemodialysis initiative, cardiovascular disease was identified as a critically important core domain to be reported in all trials in hemodialysis. Informed by the current state of reporting of cardiovascular outcomes, a core outcome measure for cardiovascular disease is currently being established with involvement of patients, caregivers, and health professionals. Consistent reporting of cardiovascular outcomes that are critically important to hemodialysis patients and clinicians will strengthen the evidence base to inform care in this very high-risk population.

Atherosclerosis in Chronic Kidney Disease: More, Less, or Just Different?

Patients with chronic kidney disease (CKD) are at an increased risk of premature mortality, mainly from cardiovascular causes. The association between CKD on hemodialysis and accelerated atherosclerosis was described >40 years ago. However, more recently, it has been suggested that the increase in atherosclerosis risk is actually observed in early CKD stages, remaining stable thereafter. In this regard, interventions targeting the pathogenesis of atherosclerosis, such as statins, successful in the general population, have failed to benefit patients with very advanced CKD. This raises the issue of the relative contribution of atherosclerosis versus other forms of cardiovascular injury such as arteriosclerosis or myocardial injury to the increased cardiovascular risk in CKD. In this review, the pathophysiogical contributors to atherosclerosis in CKD that are shared with the general population, or specific to CKD, are discussed. The NEFRONA study (Observatorio Nacional de Atherosclerosis en NEFrologia) prospectively assessed the prevalence and progression of subclinical atherosclerosis (plaque in vascular ultrasound), confirming an increased prevalence of atherosclerosis in patients with moderate CKD. However, the adjusted odds ratio for subclinical atherosclerosis increased with CKD stage, suggesting a contribution of CKD itself to subclinical atherosclerosis. Progression of atherosclerosis was closely related to CKD progression as well as to the baseline presence of atheroma plaque, and to higher phosphate, uric acid, and ferritin and lower 25(OH) vitamin D levels. These insights may help design future clinical trials of stratified personalized medicine targeting atherosclerosis in patients with CKD. Future primary prevention trials should enroll patients with evidence of subclinical atherosclerosis and should provide a comprehensive control of all known risk factors in addition to testing any additional intervention or placebo.

Inhibition of Interleukin-1β by Canakinumab and Cardiovascular Outcomes in Patients With Chronic Kidney Disease

BACKGROUND

Inflammation contributes to chronic kidney disease (CKD), in part mediated through activation of interleukin (IL)-1β by the NLRP3 inflammasome within the kidney. This process also likely contributes to the accelerated atherosclerosis associated with nephropathy.

OBJECTIVES

The authors hypothesized that canakinumab, a human monoclonal antibody targeting IL-1β, might reduce cardiovascular event rates and improve renal function among post-myocardial infarction patients with CKD.

METHODS

Stable post-myocardial infarction patients with high-sensitivity C-reactive protein (hsCRP) ≥ 2mg/l were randomly allocated to placebo or to 1 of 3 doses of canakinumab (50, 150, or 300 mg) given subcutaneously once every 3 months. Participants were followed for incident myocardial infarction, stroke, hospitalization for unstable angina requiring urgent revascularization, cardiovascular death, or death from any cause over a median follow-up period of 3.7 years (maximum 5 years). All patients additionally had serial monitoring of estimated glomerular filtration rate (eGFR), creatinine, the urine albumin to creatinine ratio (uACR), and were monitored for adverse renal and urinary events.

RESULTS

Of 10,061 participants, 1,875 (18.6%) had baseline eGFR <60 ml/min/1.73 m². These moderate CKD patients had higher incidence rates for major adverse vascular events compared with those with eGFR ≥60 ml/min/1.73 m² (6.92 vs. 4.13 per 100 person-years; p < 0.0001). Random allocation to canakinumab reduced the risk of major adverse cardiovascular events among those with CKD (hazard ratio: 0.82; 95% confidence interval: 0.68 to 1.00; p = 0.05) with the largest cardiovascular benefits accruing among those who achieved on-treatment hsCRP levels below 2 mg/l measured after taking the first dose (hazard ratio: 0.68; 95% confidence interval: 0.53 to 0.86; p = 0.0015). Comparable effects were observed among those with baseline albuminuria or diabetes. Canakinumab had neither clinically meaningful benefits nor substantive harms with respect to serial measures of eGFR, creatinine, the uACR, or reported adverse renal events during trial follow-up.

CONCLUSIONS

IL-1β inhibition with canakinumab reduces major adverse cardiovascular event rates among high-risk atherosclerosis patients with CKD, particularly among those with a robust anti-inflammatory response to initial treatment. These cardiovascular benefits accrued with no adverse clinical renal events. (Canakinumab Anti-inflammatory Thrombosis Outcomes Study [CANTOS]; NCT01327846).

Postponement of Death by Statin Use: a Systematic Review and Meta-analysis of Randomized Clinical Trials

BACKGROUND

The average postponement of the outcome (gain in time to event) has been proposed as a measure to convey the effect of preventive medications. Among its advantages over number needed to treat and relative risk reduction is a better intuitive understanding among lay persons.

OBJECTIVES

To develop a novel approach for modeling outcome postponement achieved within a trial's duration, based on published trial data and to present a formalized meta-analysis of modeled outcome postponement for all-cause mortality in statin trials.

METHODS

The outcome postponement was modeled on the basis of the hazard ratio or relative risk, the mortality rate in the placebo group and the trial's duration. Outcome postponement was subjected to a meta-analysis. We also estimated the average outcome postponement as the area between Kaplan-Meier curves. Statin trials were identified through a systematic review.

RESULTS

The median modeled outcome postponement was 10.0 days (interquartile range, 2.9-19.5 days). Meta-analysis of 16 trials provided a summary estimate of outcome postponement for all-cause mortality of 12.6 days, with a 95% postponement interval (PI) of 7.1-18.0. For primary, secondary, and mixed prevention trials, respectively, outcome postponements were 10.2 days (PI, 4.0-16.3), 17.4 days (PI, 6.0-28.8), and 8.5 days (PI, 1.9-15.0).

CONCLUSIONS

The modeled outcome postponement is amenable to meta-analysis and may be a useful approach for presenting the benefits of preventive interventions. Statin treatment results in a small increase of average survival within the duration of a trial.

SYSTEMATIC REVIEW REGISTRATION

The systematic review was registered in PROSPERO [CRD42016037507] .

Cognitive Impairment in CKD: Pathophysiology, Management, and Prevention

Patients with chronic kidney disease (CKD) are at substantially higher risk for developing cognitive impairment compared with the general population, and both lower glomerular filtration rate and the presence of albuminuria are associated with the development of cognitive impairment and poorer cognitive function. Given the excess of vascular disease seen in individuals with CKD, cerebrovascular disease is likely the predominant pathology underlying these associations, though impaired clearance of uremic metabolites, depression, sleep disturbance, anemia, and polypharmacy may also contribute. Modification of vascular disease risk factors may be helpful in limiting decline, though definite data are lacking. Specific to CKD, targeting a low blood pressure and reduction in albuminuria with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may slow cognitive decline, albeit modestly. Initiation of dialysis can improve severe impairment associated with uremia but does not appear to affect more subtle chronic cognitive impairment. In contrast, kidney transplantation appears to lead to improved cognitive function in many transplant recipients, suggesting that dialysis methods do not provide the same cognitive benefits as having a functioning kidney. Management of patients with both CKD and cognitive impairment should include a comprehensive plan including more frequent follow-up visits; involvement of family in shared decision making; measures to improve compliance, such as written instruction and pill counts; and a focus on advance directives in conjunction with an emphasis on understanding an individual patient's life goals. Further research is needed on novel therapies, including innovative dialysis methods, that aim to limit the development of cognitive impairment, slow decline in those with prevalent impairment, and improve cognitive function.

Icosapent ethyl reduces atherogenic markers in high-risk statin-treated patients with stage 3 chronic kidney disease and high triglycerides

Objective: Patients with chronic kidney disease (CKD) have increased cardiovascular disease (CVD) risk, likely driven by atherogenic and inflammatory markers beyond low-density lipoprotein cholesterol (LDL-C). The objective of this hypothesis-generating post hoc subgroup analysis was to explore the effects of icosapent ethyl at 2 or 4 g/day (prescription pure ethyl ester of the omega-3 fatty acid eicosapentaenoic acid [EPA]) on atherogenic lipid, apolipoprotein, inflammatory parameters (high-sensitivity C-reactive protein [hsCRP], lipoprotein-associated phospholipase A₂ [Lp-PLA₂]), and oxidative parameters (oxidized-LDL [ox-LDL]) in statin-treated patients from ANCHOR with stage 3 CKD.Methods: The 12-week ANCHOR study evaluated icosapent ethyl in 702 statin-treated patients at increased CVD risk with triglycerides (TG) 200-499 mg/dL despite controlled LDL-C (40-99 mg/dL). This post-hoc analysis included patients from ANCHOR with stage 3 CKD (estimated glomerular filtration rate [eGFR] ≤60 mL/min/1.73 m² for ≥3 months) randomized to icosapent ethyl 4 g/day (n = 19), 2 g/day (n = 30), or placebo (n = 36).Results: At the prescription dose of 4 g/day, icosapent ethyl significantly reduced TG (-16.9%; P = 0.0074) and other potentially atherogenic lipids/lipoproteins, ox-LDL, hsCRP, and Lp-PLA₂, and increased plasma and red blood cell EPA levels (+879% and +579%, respectively; both P < 0.0001) versus placebo. Icosapent ethyl did not significantly alter eGFR or serum creatinine. Safety and tolerability were similar to placebo.Conclusions: In patients with stage 3 CKD at high CVD risk with persistent high TG despite statins, icosapent ethyl 4 g/day reduced potentially atherogenic and other cardiovascular risk factors without raising LDL-C, with safety similar to placebo. These findings suggest prospective investigation may be warranted.

The Impact of Vascular Access Types on Hemodialysis Patient Long-term Survival

Vascular access (VA) is the cornerstone for carrying out hemodialysis, yet it may bring in complications and leads to hemodialysis quality decline. This study aimed to explore the impact of vascular access types, including arteriovenous shunts and central venous catheter on all-cause mortality after adjustment of other risk factors. Total 738 ESRD patients aged over 40 year old receiving regular hemodialysis therapies were recruited between January 2001 and December 2010 from a single hemodialysis center in northern Taiwan. We ascertained the causes and date of death by linking our hospital database with Nationwide Mortality Registry Database. VA types and biochemistry parameters were extracted from the electronic hospital records. Patients were categorized into three groups, including (1)arteriovenous shunts (AVF)/arteriovenous shunts with Gortex®(AVG); (2)AVF/AVG combined central venous catheter; (3)catheter only. The time-dependent influence of vascular types i.e. initiation and follow-up period was also assessed. The mean follow-up time was 4.5 years. In patients using central venous catheter for initiation of hemodialysis, the adjusted hazard ratio (HR) for all-cause mortality was 1.55(95%CI: 1.09, 2.21), when compared with AVF/AVG. In the follow-up period, after adjustment for other risk factors, the multivariable analysis showed that the adjusted HRs were 3.23(95%CI: 1.85, 5.64) and 1.45(95%CI: 1.11, 1.91) for catheter only and AVF/AVG plus catheter, respectively. Our results showed that vascular accesses used for hemodialysis had different and time-dependent impact on patients' long-term survival. Patients who started hemodialysis with central venous catheter had significantly higher all-cause mortality rate. Furthermore, in the follow-up period, patients both in the catheter only and AVF/AVG plus catheter groups also had the significant all-cause mortality rates. Our results support the early establishment of arteriovenous shunt for the chronic kidney disease patients.

Extreme Atherosclerotic Cardiovascular Disease (ASCVD) Risk Recognition

PURPOSE OF REVIEW

To distinguish extreme and very high atherosclerotic cardiovascular disease (ASCVD) event risk based on prospective epidemiological studies and clinical trial results.

RECENT FINDINGS

Clinical practice guidelines have categorized patients with either a history of one or more "clinical ASCVD" events or "coronary heart disease (CHD) risk equivalency" to be at "very high risk" for a recurrence or a first event, respectively. A 20% or greater 10-year ASCVD risk for a composite 3-point "major" atherosclerotic cardiovascular event (MACE) of non-fatal myocardial infarction (MI), non-fatal stroke, or cardiovascular death can serve as an arbitrary definition of those at "very high risk." Exclusion of stroke may underestimate risk of "hard" endpoint 10-year ASCVD risk and addition of other potential endpoints, e.g., hospital admission for unstable angina or revascularization, a 5-point composite MACE, may overinflate the risk definitions and categorization. "Extreme" risk, a descriptor for even higher morbidity and mortality potential, defines a 30% or greater 10-year 3-point MACE (ASCVD) risk. In prospective, epidemiological studies and randomized clinical trial (RCT) participants with an initial acute coronary syndrome (ACS) within several months of entry into the study meet the inclusion criteria assignment for extreme risk. In survivors beyond the first year of an ASCVD event, "extreme" risk persists when one or more comorbidities are present, including diabetes, heart failure (HF), stage 3 or higher chronic kidney disease (CKD), familial hypercholesterolemia (FH), and poorly controlled major risk factors such as hypertension and persistent tobaccoism. "Extreme" risk particularly applies to those with progressive or multiple clinical ASCVD events in the same artery, same arterial bed, or polyvascular sites, including unstable angina and transient ischemic events. Identifying asymptomatic individuals with extensive subclinical ASCVD at "extreme" risk is a challenge, as risk engine assessment may not be adequate; individuals with genetic FH or those with diabetes and Agatston coronary artery calcification (CAC) scores greater than 1000 exemplify such threatening settings and opportunities for aggressive primary prevention. Heterogeneity exists among individuals at risk for clinical ASCVD events; identifying those at "extreme" risk, a more ominous ASCVD category, associated with greater morbidity and mortality, should prompt the most effective global cardiometabolic risk reduction.

Lipotoxicity in Kidney, Heart, and Skeletal Muscle Dysfunction

Dyslipidemia is a common nutritional and metabolic disorder in patients with chronic kidney disease. Accumulating evidence supports the hypothesis that prolonged metabolic imbalance of lipids leads to ectopic fat distribution in the peripheral organs (lipotoxicity), including the kidney, heart, and skeletal muscle, which accelerates peripheral inflammation and afflictions. Thus, lipotoxicity may partly explain progression of renal dysfunction and even extrarenal complications, including renal anemia, heart failure, and sarcopenia. Additionally, endoplasmic reticulum stress activated by the unfolded protein response pathway plays a pivotal role in lipotoxicity by modulating the expression of key enzymes in lipid synthesis and oxidation. Here, we review the molecular mechanisms underlying lipid deposition and resultant tissue damage in the kidney, heart, and skeletal muscle, with the goal of illuminating the nutritional aspects of these pathologies.

High Cardiovascular Risk Profile in Young Patients on the Kidney Transplant Waiting List

BACKGROUND

Cardiovascular complications are the leading causes of morbidity and mortality in patients with end-stage renal disease. The risk profile very often contributes to their death while on the waiting list. Most studies have been carried out in older patients with end-stage renal disease, reflecting the general dialysis population. The aim of this study was to analyze the risk profile in young patients with advanced chronic kidney disease on the kidney transplant waiting list.

METHODS

This was a retrospective, single-center study of 748 patients on the kidney transplant waiting list at the University Hospital Essen, Germany. Clinical and laboratory parameters were collected between 2015 and 2016.

RESULTS

Of 748 patients (62% male), the median age was 48 years. Hypertension, coronary heart disease, and diabetes mellitus were the leading comorbidities, and their frequency rose significantly with age. Their median laboratory values did not differ significantly depending on age except for albumin. Hyperuricemia was quite common in our population with a prevalence of about 75% in women and 50% in men throughout all age groups. A total of 26.6% of the patients between 18 and 35 years of age had advanced anemia (hemoglobin < 10 g/dL), and thus they were affected most frequently. Elevated C-reactive protein serum levels were observed in 37.2% of the patients. Regarding the lipid profile, we observed that HDL cholesterol was within the normal range in only among 51.9% of men and 44.3% of women.

CONCLUSIONS

Cardiovascular risk factors are quite common in our cohort and affect young patients similarly.

Sudden Cardiac Death in End-Stage Renal Disease

The challenge presented by sudden cardiac death in dialysis patients is to better define risk factors and delineate multiple etiologies. Only then can therapy be tailored to the highest risk patients and the incidence of sudden cardiac death be reduced. This article details the many possible etiologies and presents a brief overview of more recent research that may in the future prove of great benefit in improving the mortality of our patients with end-stage renal disease.

Clinical trials in end-stage renal disease-priorities and challenges

Patients with end-stage renal disease (ESRD) experience extremely high morbidity and mortality and there are virtually no therapeutic interventions besides dialysis treatment that are proven in properly designed randomized controlled trials (RCTs) to improve patients' outcomes. Historically, the number of RCTs performed in the ESRD population has been very low compared with other medical subspecialties, and several of the few large RCTs have yielded inconclusive or negative results, dampening enthusiasm for future investment in similar trials. Recent initiatives promoting a focus on patient-centered outcomes and more active patient and caregiver involvement in the planning and conduct of clinical trials may result in more clinically relevant RCTs and broader participation from patients representing the diversity of the ESRD population. The adoption of novel clinical trial design elements characteristic of pragmatic clinical trials and platform trials could help improve both the internal and external validity of RCTs in ESRD, ultimately resulting in the adoption of therapeutic interventions that can be rapidly translated to clinical practice.

Proprotein convertase subtilisin/kexin type 9 and mortality in patients starting hemodialysis

BACKGROUND

Cardiovascular events are the leading cause of death in end stage renal disease (ESRD), but traditional markers of dyslipidemia are not clearly associated with cardiovascular risk in this population. Proprotein Convertase Subtilsin/Kexin type 9 (PCSK-9) could be of interest as a novel cardiovascular risk marker in ESRD due to the emergence of lipid lowering therapy based on PCSK-9 inhibition. The aim of the present study was to investigate if the convertase PCSK-9 is a potential risk marker for mortality among patients starting haemodialysis treatment.

MATERIALS AND METHODS

This is a cohort study of 265 patients starting haemodialysis between 1991-2009, with 3 years follow-up. The association between baseline PCSK-9 levels and mortality was assessed using Cox proportional hazards- and quantile regression models, with adjustment for potential confounders.

RESULTS

PCSK-9 levels at initiation of haemodialysis were associated to mortality in multivariable adjusted analysis. PCSK-9 levels exhibited an U-shaped association to mortality. Inclusion of the quadratic term of PCSK-9 in regression modelling optimized model performance. At baseline, PCSK-9 levels had positive correlations to Davies comorbidity score, haemoglobin and C-reactive protein while negative correlations were found for high-density lipoprotein and total cholesterol. PCSK-9 levels were higher in statin users and patients with a history of cardiovascular disease.

CONCLUSIONS

This study shows, for the first time, that the level of PCSK-9 is associated with all-cause mortality in haemodialysis patients, independently of a number of potential confounders.

Cholesterol-Lowering Treatment in Chronic Kidney Disease: Multistage Pairwise and Network Meta-Analyses

Pairwise and network meta-analyses on the relationship between the efficacy of the use of statins with or without ezetimibe and reductions in low-density lipoprotein cholesterol (LDLc) and C-reactive protein (CRP) in patients with chronic kidney disease (CKD) are presented. In the pairwise meta-analysis, statins with or without ezetimibe were shown to be efficacious in reducing major adverse cardiovascular events (MACE) in patients with CKD and an estimated glomerular filtration rate (eGFR) of less than 60 ml/min/1.73 m², in the context of both primary prevention [odds ratio (OR)/95% confidence interval (95% CI)/I²/number of studies (n): 0.50/0.40–0.64/0%/6] and primary/secondary prevention (0.66/0.57–0.76/57%/18). However, in the Bayesian network meta-analysis, compared to the placebo, only atorvastatin 80 mg daily and atorvastatin and rosuvastatin at doses equivalent to simvastatin 20 mg daily reduced the odds of MACEs in this patient population. The network meta-analysis for LDLc and CRP treatment objectives also showed that, regardless of eGFR and excluding dialysis patients, the number of MACEs decreased in patients with CKD, with reductions in both LDLc and CRP of less than 50% (surface under the cumulative ranking (SUCRA)/heterogeneity (vague)/n: 0.77/0.14/3). The evaluation of the benefits of drugs may lead to individualized therapy for CKD patients: Cholesterol-lowering treatment for CKD patients with high levels of both LDLc and CRP is suggested.

Statin Adherence and Mortality in Patients Aged 80 Years and Older After Acute Myocardial Infarction

BACKGROUND/OBJECTIVES

The goal of this study was to describe the pattern of statin adherence in older patients, aged 80 years or older; identify factors associated with high adherence; and determine the association between statin adherence and all-cause mortality.

DESIGN

Retrospective population-based cohort study.

SETTING

An integrated healthcare system in Southern California.

PARTICIPANTS

Patients hospitalized with a principal diagnosis of acute myocardial infarction (MI) between January 1, 2006, and December 31, 2016.

MEASUREMENTS

Statin adherence, as measured using pharmacy dispensing records over the 365 days following hospital discharge, based on proportion of days covered (PDC). Adherence levels were categorized as high (PDC 80% or higher), partial (PDC 40% or higher and lower than 80%), and low (PDC lower than 40%).

RESULTS

Between 2006 and 2016, 5629 patients, 80 years or older, hospitalized for acute MI met the inclusion criteria. Among this group, 68.8% were highly adherent to statin therapy, 20.4% were partially adherent, and 10.8% were not adherent. Male sex (odds ratio [OR] = 1.42; 95% confidence interval [CI] = 1.25-1.62) and white race (OR = 1.35; 95% CI = 1.18-1.55) were associated with high statin adherence. Follow-up was 4.3 ± 2.6 years. Both low and partial adherence were associated with increase mortality (low adherence: adjusted hazard radio [HR] = 1.12; 95% CI = 1.01-1.25; partial adherence: adjusted HR = 1.22; 95% CI = 1.12-1.32).

CONCLUSIONS

In older patients, aged 80 years or older, high adherence to statins after MI was associated with improved survival. This association may not have been due only to adherence to statins but to other related factors as well. Findings from this study may inform discussions on the potential benefits of statin adherence. J Am Geriatr Soc 67:2045-2049, 2019.

Diagnosis and treatment of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis

This review represents different aspects of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis. We discuss difficulties in diagnosis, optimal method of coronary revascularization, timing of hemodialysis session, medical therapy, as well as epidemiology and prognosis. There are no unambiguous answers to these problems because patients with end - stage renal disease were excluded from most of the studies.

Lipids and Renal Disease

The column in this issue is supplied by Anita Shah, M.D., and Juan Jose Olivero, M.D. Dr. Shah is a first-year nephrology fellow at Baylor College of Medicine in Houston, Texas. She earned her medical degree from The University of Texas Medical Branch at Galveston and completed an internal medicine residency at Houston Methodist Hospital. Dr. Olivero is a nephrologist at Houston Methodist Hospital and a member of the hospital's Nephrology Training Program. He obtained his medical degree from the University of San Carlos School of Medicine in Guatemala, Central America, and completed his residency and nephrology fellowship at Baylor College of Medicine in Houston, Texas.

An in-depth analysis shows a hidden atherogenic lipoprotein profile in non-diabetic chronic kidney disease patients

Background: Chronic kidney disease (CKD) is an independent risk factor for atherosclerotic disease. We hypothesized that CKD promotes a proatherogenic lipid profile modifying lipoprotein composition and particle number. Methods: Cross-sectional study in 395 non-diabetic individuals (209 CKD patients and 186 controls) without statin therapy. Conventional lipid determinations were combined with advanced lipoprotein profiling by nuclear magnetic resonance, and their discrimination ability was assessed by machine learning. Results: CKD patients showed an increase of very-low-density (VLDL) particles and a reduction of LDL particle size. Cholesterol and triglyceride content of VLDLs and intermediate-density (IDL) particles increased. However, low-density (LDL) and high-density (HDL) lipoproteins gained triglycerides and lost cholesterol. Total-Cholesterol, HDL-Cholesterol, LDL-Cholesterol, non-HDL-Cholesterol and Proprotein convertase subtilisin-kexin type (PCSK9) were negatively associated with CKD stages, whereas triglycerides, lipoprotein(a), remnant cholesterol, and the PCSK9/LDL-Cholesterol ratio were positively associated. PCSK9 was positively associated with total-Cholesterol, LDL-Cholesterol, LDL-triglycerides, LDL particle number, IDL-Cholesterol, and remnant cholesterol. Machine learning analysis by random forest revealed that new parameters have a higher discrimination ability to classify patients into the CKD group, compared to traditional parameters alone: area under the ROC curve (95% CI), .789 (.711, .853) vs .687 (.611, .755). Conclusions: non-diabetic CKD patients have a hidden proatherogenic lipoprotein profile.

Role of Statin Therapy in Primary Prevention of Cardiovascular Disease in Elderly Patients

Purpose of Review

Hypercholesterolemia and statin treatment are nowadays common among people older than 75 years, but clinical heterogeneity in this increasing age group is wide, and treatment decisions may differ from those in younger patients. Aim is to discuss the presentation, modifying factors, and treatment decisions of hypercholesterolemia (usually with statins) in older persons and focusing on primary prevention.

Recent Findings

There are no randomized controlled trials in persons older than 80 years at baseline. Randomized controlled trial findings in younger patients and 75+ subgroups and in observational studies support treatment in secondary prevention of atherosclerotic cardiovascular disease (ASCVD), but trial evidence in primary prevention is less clear. Available data do not imply specific harms in older patients, and, therefore, also, judicious primary prevention is possible. However, persons older than 75 years are biologically a very heterogeneous group with frequent frailty, comorbid conditions, and multiple concomitant drugs. All these, as well as personal preferences, must be taken into account in treatment decisions.

Summary

Statin treatment is only one way to prevent ASCVD in older people. Treatment of hypercholesterolemia should be started far before 75–80 years, and there is no need to discontinue statin treatment due to chronological age alone. After 75 years, treatment should be started in patients with ASCVD and judiciously in primary prevention. Like all prevention, statin treatment should be discontinued when palliative treatment is started. Ongoing and planned trials in 70+ individuals will give more information about primary prevention in older persons.

Exome-Based Rare-Variant Analyses in CKD

BACKGROUND

Studies have identified many common genetic associations that influence renal function and all-cause CKD, but these explain only a small fraction of variance in these traits. The contribution of rare variants has not been systematically examined.

METHODS

We performed exome sequencing of 3150 individuals, who collectively encompassed diverse CKD subtypes, and 9563 controls. To detect causal genes and evaluate the contribution of rare variants we used collapsing analysis, in which we compared the proportion of cases and controls carrying rare variants per gene.

RESULTS

The analyses captured five established monogenic causes of CKD: variants in PKD1, PKD2, and COL4A5 achieved study-wide significance, and we observed suggestive case enrichment for COL4A4 and COL4A3. Beyond known disease-associated genes, collapsing analyses incorporating regional variant intolerance identified suggestive dominant signals in CPT2 and several other candidate genes. Biallelic mutations in CPT2 cause carnitine palmitoyltransferase II deficiency, sometimes associated with rhabdomyolysis and acute renal injury. Genetic modifier analysis among cases with APOL1 risk genotypes identified a suggestive signal in AHDC1, implicated in Xia-Gibbs syndrome, which involves intellectual disability and other features. On the basis of the observed distribution of rare variants, we estimate that a two- to three-fold larger cohort would provide 80% power to implicate new genes for all-cause CKD.

CONCLUSIONS

This study demonstrates that rare-variant collapsing analyses can validate known genes and identify candidate genes and modifiers for kidney disease. In so doing, these findings provide a motivation for larger-scale investigation of rare-variant risk contributions across major clinical CKD categories.

Arteriovenous fistula thrombosis is associated with increased all-cause and cardiovascular mortality in haemodialysis patients from the AURORA trial

Background

The impact of arteriovenous fistula (AVF) or graft (AVG) thrombosis on mortality has been sparsely studied. This study investigated the association between AVF/AVG thrombosis and all-cause and cardiovascular mortality.

Methods

The data from 2439 patients with AVF or AVG undergoing maintenance haemodialysis (HD) included in the A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events trial (AURORA) were analysed using a time-dependent Cox model. The incidence of vascular access (VA) thrombosis was a pre-specified secondary outcome.

Results

During follow-up, 278 AVF and 94 AVG thromboses were documented. VA was restored at 22 ± 64 days after thrombosis (27 patients had no restoration with subsequent permanent central catheter). In multivariable survival analysis adjusted for potential confounders, the occurrence of AVF/AVG thrombosis was associated with increased early and late all-cause mortality, with a more pronounced association with early all-cause mortality {hazard ratio [HR] < 90 days 2.70 [95% confidence interval (CI) 1.83–3.97], P < 0.001; HR > 90 days 1.47 [1.20–1.80], P < 0.001}. In addition, the occurrence of AVF thrombosis was significantly associated with higher all-cause mortality, whether VA was restored within 7 days [HR 1.34 (95% CI 1.02–1.75), P = 0.036] or later than 7 days [HR 1.81 (95% CI 1.29–2.53), P = 0.001].

Conclusions

AVF/AVG thrombosis should be considered as a major clinical event since it is strongly associated with increased mortality in patients on maintenance HD, especially in the first 90 days after the event and when access restoration occurs >7 days after thrombosis. Clinicians should pay particular attention to the timing of VA restoration and the management of these patients during this high-risk period. The potential benefit of targeting overall patient risk with more aggressive treatment after AVF/AVG restoration should be further explored.

Statin therapy among chronic kidney disease patients presenting with acute coronary syndrome

BACKGROUND AND AIMS

The beneficial effect of statin therapy has been well established for both primary and secondary prevention of cardiovascular disease. Nevertheless, it remains under-used among patients with chronic kidney disease (CKD). We aimed to investigate the impact of statin therapy across a wide spectrum of CKD patients presenting with acute coronary syndrome (ACS).

METHODS

We included all patients with ACS enrolled in the Acute Coronary Syndrome Israel Survey (ACSIS) between the years 2006 and 2016, and allocated them to 3 groups according to their renal function based on an estimated glomerular filtration rate (eGFR) calculation on admission (MDRD formula): eGFR<30 ml/min/1.73 m² (n = 525, 6%), eGFR 30-59 ml/min/1.73 m² (n = 1919, 21%), and eGFR>60 ml/min/1.73 m² (n = 6501, 73%). Primary outcome included in-hospital, 30-day, and 1-year major adverse cardiovascular events (MACE), and the independent prognostic effect of statins among CKD patients with ACS, by Cox regression analysis.

RESULTS

All 8945 consecutive ACS patients were included in our analysis. On hospital discharge, statin prescriptions were negatively associated with eGFR ]eGFR>60 ml/min/1.73 m² -95%, eGFR 30-59 ml/min/1.73 m² -90%, eGFR<30 ml/min/1.73 m² -78% (p < 0.001 for trend). Kaplan-Meier curves demonstrated both short and long-term higher mortality rates in those prescribed compared with those not prescribed statins (p < 0.001), regardless of renal function. Cox regression analysis revealed the protective effect of discharge statins (HR-0.25, 95% C.I 0.2-0.3, p < 0.001).

CONCLUSIONS

In our study, the beneficial effect of statins was maintained among CKD patients presenting with ACS. Therefore, these patients should be treated with statins regardless of their eGFR.

Arterial Stiffness in the Heart Disease of CKD

CKD frequently leads to chronic cardiac dysfunction. This complex relationship has been termed as cardiorenal syndrome type 4 or cardio-renal link. Despite numerous studies and reviews focused on the pathophysiology and therapy of this syndrome, the role of arterial stiffness has been frequently overlooked. In this regard, several pathogenic factors, including uremic toxins (i.e., uric acid, phosphates, endothelin-1, advanced glycation end-products, and asymmetric dimethylarginine), can be involved. Their effect on the arterial wall, direct or mediated by chronic inflammation and oxidative stress, results in arterial stiffening and decreased vascular compliance. The increase in aortic stiffness results in increased cardiac workload and reduced coronary artery perfusion pressure that, in turn, may lead to microvascular cardiac ischemia. Conversely, reduced arterial stiffness has been associated with increased survival. Several approaches can be considered to reduce vascular stiffness and improve vascular function in patients with CKD. This review primarily discusses current understanding of the mechanisms concerning uremic toxins, arterial stiffening, and impaired cardiac function, and the therapeutic options to reduce arterial stiffness in patients with CKD.

Risk Stratification and Treatment of Coronary Disease in Chronic Kidney Disease and End-Stage Kidney Disease

Patients with advanced chronic kidney disease have an enormous burden of cardiovascular morbidity and mortality, but, paradoxically, their representation in randomized trials for the evaluation and management of coronary artery disease has been limited. Clinicians therefore are faced with the conundrum of synergizing evidence from observational studies, expert opinion, and extrapolation from the general population to provide care to this complex and clinically distinct patient population. In this review, we address clinical risk stratification of patients with chronic kidney disease and end-stage kidney disease using traditional cardiovascular risk factors, noninvasive functional and structural cardiac imaging, invasive coronary angiography, and cardiovascular biomarkers. We highlight the unique characteristics of this population, including the high competing risk of all-cause mortality relative to the risk of major adverse cardiac events, likely owing to important contributions from nonatherosclerotic mechanisms. We further discuss the management of coronary artery disease in patients with chronic kidney disease and end-stage kidney disease, including evidence pertaining to medical management, coronary revascularization with percutaneous coronary intervention, and coronary artery bypass grafting. Our discussion includes considerations of drug-eluting versus bare metal stents for percutaneous coronary intervention and off-pump versus on-pump coronary artery bypass graft surgery. Finally, we address currently ongoing randomized trials, from which clinicians are optimistic about receiving guidance regarding the best strategies to incorporate into their practice for the evaluation and management of coronary artery disease in this high-risk population.

Tackling Residual Atherosclerotic Risk in Statin-Treated Adults: Focus on Emerging Drugs

Epidemiological studies and meta-analyses have consistently suggested the importance of lowering low-density lipoprotein cholesterol (LDL-C) to reduce cardiovascular (CV) events. However, these studies and mechanistic studies using intracoronary imaging modalities have reported patients who continue to experience CV events or disease progression despite optimal LDL-C levels on statins. These findings, including statin intolerance, have highlighted the importance of exploring additional potential therapeutic targets to reduce CV risk. Genomic insights have presented a number of additional novel targets in lipid metabolism. In particular, proprotein convertase subtilisin/kexin type 9 inhibitors have rapidly developed and recently demonstrated their beneficial impact on CV outcomes. Triglyceride (TG)-rich lipoproteins have been recently reported as a causal factor of atherosclerotic cardiovascular disease (ASCVD). Indeed, several promising TG-targeting therapies are being tested at various clinical stages. In this review, we present the evidence to support targeting atherogenic lipoproteins to target residual ASCVD risk in statin-treated patients.

Brain white matter microstructure in end-stage kidney disease, cognitive impairment, and circulatory stress

INTRODUCTION

Structural and functional brain white matter abnormalities are poorly characterized in patients with end-stage kidney disease.

METHODS

We examined the prevalence of the brain white matter microstructure disruption using diffusion tensor magnetic resonance imaging and its association with hemodynamic performance and cognitive defects in 49 incident hemodialysis (HD) patients and compared these to 25 age-matched normal controls. We analyzed fractional anisotropy (FA) and mean diffusivity (MD) maps of the images, a voxelwise statistical analysis was done using tract-based spatial statistics. Hemodynamic assessment was done using extrema points analysis model of continuous blood pressure monitoring.

FINDINGS

We found significant white matter damage in HD patients compared with normal controls (peak FA 0.471 ± 0.031 vs 0.486 ± 0.022 P = 0.023, peak MD 0.00194 ± 0.000363 10^-3 mm² .s^-1 vs 0.00167 ± 0.0003 10^-3 mm² .s^-1 P = 0.002). There was diffuse pattern of white matter damage in HD patients, which was independent of age, gender, and the presence of ischaemic heart disease and diabetes with significantly lower FA values in HD patients than normal controls (0.467 ± 0.037 vs 0.507 ± 0.026, P < 0.05 corrected for family wise error. HD patients had worse cognitive scores that correlated with white matter damage (for peak FA, Montreal cognitive assessment r = 0.478 P = 0.001, Trail A r = -0.486 P = 0.001, Trail B r = -0.464 P = 0.001; for peak MD, Montreal cognitive assessment r = -0.533 P < 0.001, Trail A r = 0.641 P < 0.001, Trail B r = 0.514 P < 0.001). In a multivariable linear regression analysis that included age, smoking, the presence of ischaemic heart disease, and diabetes mellitus, higher frequency of mean arterial blood pressure extrema points during HD was independently associated with white matter damage (β = -0.296, P = 0.036, Adjusted R² for the whole model = 0.400).

DISCUSSION

End-stage kidney disease patients on HD have more brain white matter damage and cognitive impairment than age-matched controls that are linked to hemodynamic functional measures.